Ramblings of an Emergency Physician in Texas

Leaving AMA: A Patient’s Perspective

In the mailbag, a very well-written exposition from a patient about leaving AMA:

I was in for a [surgery] and had jumped through all the hoops (completed basic physical therapy, and my bowels and urine system were up and running).

[Surgery] was ready to release me but noticed and elevated resting pulse. It cost me two days in the hospital and testing found nothing except when my body is stressed, my resting pulse is high.

Here’s the issue. I was miserable for those two days. I wanted to be home. I like the scale that hospitals use to describe pain 1 to 10 and don’t let it get much over 3 because it will set you back. Let’s substitute mental emotional pain for physical pain. Anger, depression, fear, panic, clostrophobia… Confinement to a hospital room, hospital gowns, and drugs exacerbate the problem. It’s hard to stay ‘grounded’. On a misery scale I was a 7 or 8.

Consider this; pain passes, misery leaves indelible marks. We see this with rape victims and returning soldiers. When the misery scale gets too high it becomes a long term issue.Here’s the problem. Someone like me who’s had a miserable indelible experience in the hospital is going to be much more difficult to get back in the hospital the next time hospitalization is needed. You can say “Quit whining and be logical” and I’m going to agree that it is not logical to avoid needed medical care, but humans don’t make decisions based on logic, at the core, decisions are usually based on emotive factors.

When you are faced with a request to leave AMA, ask about the misery scale level. Can you do anything to relieve the stressors? Will hospital privileges help? Is what we are doing really that urgent? Can I contract with the patient for outpatient followup? Remember it’s not just the short term medical issues, and they may override the patient’s misery level, it’s also the long term ability to have your patient believe that a doctor is truly their advocate for health.

That’s an excellent presentation of just some of the stressors that induce patients to leave AMA.

When notified someone wants to leave AMA, we ‘offer all services of the hospital’, but often that’s not well understood (by either side in the conversation). And generally all offers fall on deaf ears, as when someone has mustered the courage to ask to leave AMA, they’re decided on leaving. The patient wants to go, but wants, usually, to be grown-up about it, announce their intentions and exit. It would be ever so much easier for them to simply walk out (I’m using my ED as an example), so I respect those who announce their intentions, though overall we tend to be very patronizing to them.

Comments

I’ve been debating how to respond to this letter, since I am sort of torn on the topic of patients going AMA. Professionally I know I should give them every respect and counsel them on the medical reasoning on why I think they should stay. Realistically though AMA patients are often being manipulative and unpleasant, invariably while I have ten other things going on with patients who are sicker than they. How far does my responsibility go and where does theirs begin? I know what a lawyer would say, is that what we should all follow?

The letter writer seems to be referring to an inpatient situation. I have done a lot of inpatient work and the issue of patients leaving AMA is much less than in the ED. I have almost always been able to come to a common agreement with an inpatient, where there is time for me to sit down for 20 or 30 minutes and go through things. In the ED there is often not that luxury, and the patient wanting to go AMA will not sit and wait until you have some spare time to talk.

On the misery scale, I think the pain scale is next to useless and so would be the misery scale. I have no doubt every patient wanting to go AMA would report a 10/10.

From the patient side: I have left an ED AMA – but I just told them I was leaving, no threats or taking up the time of the ED doc. This was after the w/u and they told me that the cause of my gross hematuria and severe renal colic could not be ascertained (had a ureteral stent placed the day before). This prestigious medical center in LA refused to Rx class 2 narcotics in the ED despite the fact that 2 vicodin q 3 hr ATC along with max ibuprofen wasn’t controlling the pain – said I’d have to be admitted for pain control- on a weekend, under a covering urologist (who I’d already called re: the pain and was told I was taking too much vicodin – D’oh!) Asked if I’d get PCA – no. So went home to suffer knowing that I’d be more comfortable in my own bed rather than in an hospital bed pushing a call light waiting for an overworked nurse to give me pain meds. Turns out I was passing the stone AROUND the stent. Pain improved the next day. Saved BC/BS and myself some money, nursed myself, avoided being miserable and in pain in the hospital. And my liver survived.
And I agree with the patient who wrote; there is a huge misery factor associated with being hospitalized – one that many providers do not recognize.

OTOH, just this week we had a patient who came in for outpatient ETT. He had early ischemic changes then had near syncope during 20 seconds of v-tach. He was admitted, then his wife refused to let him have a cath. He left AMA within a short time despite the fellow and attending talking with him for 30 min each. Part of the discussion was the need to report him to the DMV – that was the only thing that almost caused him to reconsider his decision. Made us wonder what kind of life insurance policy he had.

I have no problem with people doing so… I just document appropriately. Even if their illness is life-threatening, competent patients have a right to determine their own care (or lack thereof). Either we believe in autonomy and patient-directed care, or we don’t.

Most of the AMAs I see are impatient people, or just flat-out jerks (it’s not usually pain… I’m pretty generous in that dept). That said, some legitimately have other things going on in their lives, and while I counsel them that their life is probably worth more than their unfinished business, the decision is theirs. I also welcome them back if they return (and some do).

I don’t get bent out of shape about it, even with the sick ones. I just go see the next patient.

I think this is a valid complaint and I also think medical professionals take this way to light. They tend to blame the patient rather than look for the real cause. Face it,blaming the patient is the easy thing to do. They are gone and good riddance to them.

I have been hospitalized as an inpatient several times. I’ve seen a steady decline in the kind of care that professionals give to their patients. I am mainly speaking of the nursing care.

My last admission was for major surgery and I was in the hospital for 6 days. It was about the worse 6 days I can remember. I was on bed rest for the first 2 days. I would call for the nurse when I had to go to the bathroom and maybe 1.5 hours later she would come in. Once I was given the wrong medicine and when I pointed it out to the nurse that this did not look like it did every other time…her response…”Well, whats your name?” when I tell her, she grabs the meds out of my hand and gives me a dirty look, like I’m the one that did something wrong. Thats just a couple examples, there were more. Some how these nurses have started acting like prison wardens and treating patients like inmates.

I also guess they are to good now to help patients that are restricted to bed, with things like bathing, worrying about position or comfort. I had a hard time figuring out just what it was that they did do.

On the other hand, with declining reimbursments, nursing shortages, and hospitals looking to save a buck anywhere they can, you could have simply run into medicine-on-the-cheap.

And yes, being an inpatient is painful. Having been one myself, I can’t imagine anyone actually wanting to be admitted to the hospital. Noisy, bad food, uncomfortable beds, inconsiderate roommates… This was some years ago, well before our current death-spiral, but even then I couldn’t wait to get out.

Your prison analogy is perfect… when I was discharged, I felt like the guy from the Shawshank Redemption.

MCA – NewGuy’s comments are accurate but I think there’s another factor, which is the shift in focus from nurses providing direct patient care to nurses filling out checklists, protocols, care plans and other paperwork. This is absolutely not a criticism of nurses by the way, most of them do a great job despite the avalanche of charting they are expected to do. The bottom line though is that time previously spent on direct patient care, comforting, etc is now spent on paperwork.

I’ve watched this evolution over the past twenty years or so where every problem has to be addressed by a new protocol or checklist. At the risk of sounding like an old fart, twenty years ago when I made rounds the nurse might leave me a little note saying Mrs. Jones had loose stools during the night and could I please check it out. Now the nurses notes are in a seperate chart that I never see and in the patient’s chart are checklists, forms and protocols, within lie buried something about what happened during the night. What’s funny is the resurgence of nurses leaving little sticky notes for me about Mrs. Jones because they know nobody can figure out what has actually happened from looking at the chart. Still, the nurses have spent an awful lot of time on charting that could have been used more effectively.

I think the change occurred for multiple reasons, one being the advent of defensive medicine, where every bit of information must be documented otherwise it’s assumed never to have happened. It’s also been pushed by JCAHO, where the answer to every problem is another checklist or protocol. Finally I think it’s come from within nursing itself especially with the emphasis on BSNs, where nursing is looked at more as academic as opposed to practical. Nursing who wish to advance become nurse administrators, who have learned to manage problems by the generation of more paperwork.

This is more a problem on the inpatient side as compared to the ED. Again this is not a criticism of nurses but rather the system they find themselves in.

The New Guy and Goatwhacker, I do think that what you say is probably alot of the reasons for the decline in one on one care. 30 some years ago when I was having my babies, one almost couldn’t wait to go to the hospital, not just because we would be getting our beautiful baby, but also because we would get babied ourself for a few days. Someone was always in the room checking to make sure you didn’t need anything, giving back rubs, etc….

Also, nurses now spend alot of time talking and laughing among themselves where in days past they spent that time with patients. I was directly across the hall from the nurses station. Loud talking and laughing, almost party like, going on all the time. In all honesty, I think the big problem is that I was just at the wrong hospital. This use to be the best hospital in our area for nursing care. Several years ago the nursing staff went union. I guess they now have so much job security that doing their job just isn’t very important.